Update Kardiogener Schock

Zusammenfassung

Der kardiogene Schock ist nach wie vor ein Krankheitsbild mit sehr hoher Mortalität. Dabei spielen ischämische Herzerkrankungen in den Ursachen die wichtigste Rolle (infarktbedingter kardiogener Schock). Somit ist auch die schnellstmögliche Revaskularisation der wichtigste Pfeiler der Therapie. Zur medikamentösen Stabilisierung kommen Vasopressoren oder (bei hohem Systemwiderstand und erhaltenem systolischen Blutdruck) auch Vasodilatatoren zur Nachlastsenkung infrage. Die Katecholamintherapie umfasst Dobutamin und Arterenol unter genauer Erfassung hämodynamischer Größen zur Therapiesteuerung. Ergänzend kommt als Kalzium-Sensitizer Levosimendan zum Einsatz. Kommt es nicht zur Stabilisierung, werden zunehmend extrakorporale Unterstützungssysteme verwendet. Zu unterscheiden sind in erster Linie Systeme mit Impeller-Pumpen und die ECMO. Gerade letztere stabilisiert nicht nur die hämodynamische, sondern auch die respiratorische Situation. Eine Weiterentwicklung stellt die pulsatile ECMO dar. Offen ist noch der richtige Zeitpunkt und die Auswahl des richtigen Patienten, der dann auch von der aufwendigen Therapie profitiert. Jedoch scheint der frühe Einsatz in der frühen Phase des kardiogenen Schockes den größten Benefit zu erbringen.

Abstract

Cardiogenic shock represents an entity associated with high mortality. Ischemic cardiac disease is the most frequent underlying cause (infarct-related cardiogenic shock). Therefore the early revascularization is of high importance. Vasopressors and also vasodilatators (in high systemic vascular resistance and preserved arterial pressure) are used for initial stabilization. The catecholamine drug therapy consists of dobutamine and norepinephrine guided by exact monitoring of hemodynamic values. Additionally, levosimendan can be given as a calcium-sensitizer in catecholamine resistant shock. If a stabilization cannot be achieved, extracorporeal support systems are used increasingly, especially impeller pumps and the ECMO. In particular the ECMO stabilizes not only the hemodynamic but also the respiratory situation. A further development is represented by the pulsatile ECMO. It is currently still under discussion, when and in whom the ECMO should be used to achieve a clear benefit from this extensive therapy. But it seems that the early usage in the early phase of the cardiogenic shock should provide the greatest benefit.

Schlüsselwörter

kardiogener Schock - Levosimendan - Katecholamine - ECMO - ECLS - medikamentöse Therapie

Key words

cardiogenic shock - levosimendan - catecholamines - ECMO - ECLS - drug therapy

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